MEN'S MEDICAL HISTORY AND SYMPTOMS

TODAY'S DATE MM/DD/YYYY
FIRST NAME
MIDDLE INITIAL
LAST NAME
STREET ADDRESS 1
STREET ADDRESS 2
CITY
STATE
ZIP CODE
HOME TELEPHONE
CELL TELEPHONE
EMAIL
DATE OF BIRTH MM/DD/YYYY
AGE
HEIGHT IN
WEIGHT POUNDS
OCCUPATION
DRUG ALLERGIES
SEASONAL ALLERGIES
PET ALLERGIES
USE TOBACCO?  HOW MUCH?   PKG/DAY
USE ALCOHOL?  HOW MUCH?   /DAY/ MO
USE CAFFEINE?  HOW MUCH?   /DAY/MO
CARBONATED BEVERAGES  DIET? HOW MUCH? OZ/ DAY/WEEK/MONTH
CURRENT MEDICATIONS?
DO YOU EXERCISE?  HOW OFTEN TIMES / WEEK

MEDICAL CONDITIONS
LIST DR'S & PHONE NO'S
   
SYMPTOMS:  
DECREASE IN URINE FLOW
INCR URINARY URGE
PROSTATE PROBLEMS
WEIGHT GAIN-CHEST/HIPS
WEIGHT GAIN-WAIST
DECREASED LIBIDO
DECREASED ERECTIONS
RINGING IN EARS
HIGH CHOLESTEROL
ELEV TRIGLYCERIDES
HOT FLASHES
NIGHT SWEATS
DECR MENTAL SHARPNESS
INCR FORGETFULLNESS
DECR MUSCLE SIZE
DECR FLEXABILITY
SORE MUSCLES
INCR JOINT PAIN
NECK OR BACK PAIN
BONE LOSS
RAPID AGING
THINNING SKIN
DECREASE IN STAMINA
BURNED OUT FEELING
STRESS LEVEL
MORNING FATIGUE
EVENING FATIGUE
DIFFICULTY SLEEPING
APATHY
DEPRESSED
MENTAL FATIGUE
ANXIOUS
IRRITABLE
NERVOUS
HEADACHES
SUGAR CRAVINGS
DIZZY SPELLS
COLD BODY TEMP
GOITER
HOARSENESS
HAIR DRY OR BRITTLE
NAILS BREAKING-BRITTLE
CONSTIPATION
SLOW PULSE RATE
RAPID HEARTBEAT
HEART PALPITATIONS
INFERTILITY PROBLEMS
ALLERGIES
   

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